Three-dimensional ultrasound VOCAL combined with contrast-enhanced ultrasound: an alternative to contrast-enhanced magnetic resonance imaging for evaluating ablation of benign uterine lesions

Figures & data

Figure 1. Three-dimensional contrast-enhanced ultrasound volumetric images (A–D).

Figure 2. Three-dimensional contrast-enhanced magnetic resonance imaging (A–F).

Figure 3. Bland–Altman plot of NPV measurements obtained via 2D-CEUS and 3D-CEMRI. (A) all patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Figure 4. Bland–Altman plot of NPV measurements obtained via 3D-VOCAL and 3D-CEMRI. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Table 1. Reliability and agreement between the two ultrasonic measurement methods and 3D-CEMRI.

	2D-CEUS and 3D-CEMRI		3D-VOCAL and 3D-CEMRI
NPV (cm^3)	ICC (95% CI)	Mean difference (95% LoA)	ICC (95% CI)	Mean difference (95% LoA)
All patients	0.891 (0.822–0.935)	6.4 (–39.6, 52.4)	0.999 (0.998–0.999)	–0.3 (–5.2, 4.6)
Different types
UM	0.918 (0.843–0.958)	0.8 (–34.8, 36.4)	0.999 (0.997–0.999)	–0.2 (–5.0, 4.6)
AM	0.875 (0.726–0.946)	15.1 (–40.1, 70.3)	0.999 (0.998–1.000)	–0.5 (–5.6, 4.6)
Different sizes
≥5 cm	0.685 (0.416–0.845)	12.9 (–49.8, 75.7)	0.998 (0.995–0.999)	–0.7 (–6.7, 5.4)
<5 cm	0.893 (0.790–0.948)	0.8 (–17.9, 19.4)	0.997 (0.993–0.998)	–0.04 (–3.6, 3.5)

2D: 2-dimensional; 3D: 3-dimensional; AM: adenomyosis; CEMRI: contrast-enhanced magnetic resonance imaging; CEUS: contrast-enhanced ultrasound; CI: confidence interval; ICC: intraclass correlation coefficient; LoA: limit of agreement; NPV: non-perfused volume; UM: uterine myoma.

Table 2. Comparison of NPV values obtained by the three measurement methods.

NPV (cm^3)	2D-CEUS	3D-VOCAL	3D-CEMRI	p0/p1/p2
All patients	66.1 ± 53.1	59.3 ± 50.1	59.6 ± 50.3	0.040/0.045/0.332
Different types
UM	61.4 ± 44.3	60.3 ± 44.1	60.6 ± 44.1	p0 = 0.781
AM	73.3 ± 64.8	57.7 ± 59.2	58.2 ± 59.8	0.017/0.020/0.553
Different sizes
≥5 cm	112.3 ± 40.4	98.7 ± 44.3	99.4 ± 44.3	0.043/0.049/0.295
<5 cm	26.0 ± 19.0	25.2 ± 21.6	25.2 ± 21.7	p0 = 0.672

2D: 2-dimensional; 3D: 3-dimensional; AM: adenomyosis; CEMRI: contrast-enhanced magnetic resonance imaging; CEUS: contrast-enhanced ultrasound; NPV: non-perfused volume; UM: uterine myoma.

p₀ is the comparison among the three inspection methods (multiple comparisons are not performed when p₀ > 0.05); p₁ is the comparison between 2D-CEUS and 3D-CEMRI; p₂ is the comparison between 3D-VOCAL and 3D-CEMRI.

Figure 5. Bland–Altman plot of the inter-observer agreement for NPV measurements obtained via 2D-CEUS. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Figure 6. Bland–Altman plot of the inter-observer agreement for NPV measurements obtained via 3D-VOCAL. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Figure 7. Bland–Altman plot of the inter-observer agreement for NPV measurements obtained via 3D-CEMRI. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Table 3. Inter-observer agreement in the three measurement methods.

	2D-CEUS		3D-VOCAL		3D-CEMRI
NPV (cm^3)	ICC (95% CI)	Mean difference (95% LoA)	ICC (95% CI)	Mean difference (95% LoA)	ICC (95% CI)	Mean difference (95% LoA)
All patients	0.897 (0.831–0.938)	8.5 (–34.1, 51.2)	0.998 (0.997–0.999）	–1.3 (–7.1, 4.5)	1.000 (0.999–1.000)	0.07 (–2.7, 2.9)
Different types
UM	0.951 (0.905–0.975)	4.9 (–20.2, 29.9)	0.997 (0.995–0.996)	–1.9 (–7.0, 3.2)	0.999 (0.999–1.000)	0.3 (–2.5, 3.0)
AM	0.860 (0.697–0.939)	14.2 (–45.5, 73.9)	0.999 (0.977–0.999)	–0.4 (–6.7, 6.0)	1.000 (0.999–1.000)	0.2 (–3.0, 2.6)
Different sizes
≥5 cm	0.687 (0.419–0.846)	14.9 (–44.7, 74.4)	0.996 (0.992–0.998)	–1.3 (–8.4, 5.7)	0.999 (0.998–1.000)	0.2 (–3.7, 4.0)
<5 cm	0.884 (0.743–0.946)	3.1 (–8.6, 14.7)	0.993 (0.985–0.997)	–1.3 (–5.8, 3.2)	0.999 (0.999–1.000)	0 (–1.4, 1.4)

2D: 2-dimensional; 3D: 3-dimensional; AM: adenomyosis; CEMRI: contrast-enhanced magnetic resonance imaging; CEUS: contrast-enhanced ultrasound; CI: confidence interval; ICC: intraclass correlation coefficient; LoA: limit of agreement; NPV: non-perfused volume; UM: uterine myoma.

Figure 8. Bland–Altman plot of the intra-observer agreement for NPV measurements obtained via 2D-CEUS. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E), patients with maximum diameter <5 cm.

Figure 9. Bland–Altman plot of the intra-observer agreement for NPV measurements obtained via 3D-VOCAL. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Figure 10. Bland–Altman plot of intra-observer agreement for NPV measurements obtained via 3D-CEMRI. (A) All patients; (B) patients with UM; (C) patients with AM; (D) patients with maximum diameter ≥5 cm; (E) patients with maximum diameter <5 cm.

Table 4. Intra-observer agreement of the three measurement methods.

	2D-CEUS		3D-VOCAL		3D-CEMRI
NPV (cm^3)	ICC (95% CI)	Mean difference (95% LoA)	ICC (95% CI)	Mean difference (95% LoA)	ICC (95% CI)	Mean difference (95% LoA)
All patients	0.950 (0.916–0.970)	3.5 (–28.3, 32.2)	0.999 (0.998–0.999)	–1.2 (–5.7, 3.5)	0.999 (0.999–1.000)	0.9 (–2.3, 4.1)
Different types
UM	0.988 (0.976–0.994)	0.7 (–13.1, 14.4)	0.998 (0.996–0.999)	–1.6 (–5.8, 2.6)	0.999 (0.999–1.000)	0.9 (–1.5, 3.3)
AM	0.921 (0.822–0.966)	7.8 (–39.3, 54.9)	0.999 (0.998–1.000)	–0.4 (–5.3, 4.5)	0.999 (0.998–1.000)	0.9 (–3.4, 5.1)
Different sizes
≥5 cm	0.845 (0.687–0.927)	7.3 (–35.9, 50.5)	0.997 (0.994–0.999)	–1.2 (–7.0, 4.5)	0.999 (0.997–0.999)	0.9 (–3.1, 4.9)
<5 cm	0.929 (0.857–0.965)	0.2 (–14.2, 14.5)	0.996 (0.991–0.998)	–1.1 (–4.5, 2.3)	0.998 (0.995–0.999)	0.9 (–1.5, 3.3)

2D: 2-dimensional; 3D: 3-dimensional; AM: adenomyosis; CEMRI: contrast-enhanced magnetic resonance imaging; CEUS: contrast-enhanced ultrasound; CI: confidence interval; ICC: intraclass correlation coefficient; LoA: limit of agreement; NPV: non-perfused volume; UM: uterine myoma.